Page 13 - AFL 2022 Grandfathered Guide with Legal Notices

DENTAL PLAN

It’s important to have regular dental exams and cleanings so problems are detected before they
become painful — and expensive. Keeping your teeth and gums clean and healthy will help prevent
most tooth decay and is an important part of maintaining your overall health. We offer two dental
plan options through Delta Dental.

Enhanced Dental PPO Basic Dental PPO
Plan Provisions AFL Pays You Pay AFL Pays You Pay

Annual Deductible $50 per person $50 per person
Annual Maximum
(For all services except orthodontia) $2,000 per person $1,000 per person

Orthodontia Lifetime Maximum $1,500 Not Covered
Diagnostic and Preventive Services
i
(e.g., X-rays, clean ngs, exams) Covered at 100% 0% Covered at 100% 0%
Basic and Restorative Services
(e.g., fillings) 80% 20% 80% 20%

Major Services 50% 50% Not covered
(e.g., dentures, crowns, bridges)
Oral Surgery 80% 20% Not covered

Orthodontia
΅ Dependents up to age 19.
(Adult Orthodontia is not covered.) 50% 50% Not covered
΅ No deductible applies

Using in-network
dental providers
While you have the option
of choosing any provider,
you will save money
when you use in-network
dentists. When using an
out-of-network dental
provider, you will pay more
because the provider has
not agreed to charge you a
negotiated rate.

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